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Lower back pain

 

Background

  • Most low back pain is ‘mechanical’ and self-limiting; however some back pain is sinister (i.e. caused by malignancy, osteoporotic fracture or due to spinal cord/cauda equina compression) and it is important to pick these people out.

 

Red Flag Symptoms in lower back pain

  • Patient
    • Age <20 or >55
    • Current or recent infection (especially TB, but staph and others will infect the spine)
    • Immunosuppression (infection)
    • Abdominal mass (malignancy)
  • Symptoms
    • Acute onset in elderly (think osteoporotic fracture)
    • Constant or progressive pain
    • Pain at night
    • Pain when supine (pain usually improves on lying flat in mechanical back problems)
    • Morning stiffness
    • Fever, high sweats, weight loss (malignancy)
    • Thoracic back pain
    • Bilateral or alternating symptoms
    • Neurological abnormalities (weakness, numbness)
    • Sphincter disturbance (incontinence of urine and faeces)
    • Leg ‘claudication’ (? Spinal stenosis)

 

Features of inflammatory back disease

  • Insidious onset
  • Onset at young age
  • Worse in the morning
  • Improves with exercise

 

Examination of the patient with back pain

  • Look for kyphosis/scoliosis
  • Spinal tenderness
  • Lumbar forward flexion (Schober’s test) and lateral flexion
  • Neurological examination
    • Including DRE if suspecting cauda equina
  • Straight leg raise
  • Systemic examination

 

Indications for MRI in lower back pain

  • If suspecting:
    • Cord compression
    • Cauda equina
    • Infection
    • Malignancy
    • Acute fracture
    • Inflammatory back disease

 

Treatment of lower back pain

If red flags positive:

  • Analgesia (see below)
  • MRI
    • No indication for lumbar XR unless suspicion of lumbar fracture (e.g. elderly patient with trauma, likely or known osteoporosis or long term steroids)
  • Refer to neurosurgeons.
    • Summary of indications for neurosurgical review
      • Cauda equina [bilateral or alternating root pain into lower legs, saddle anaesthesia, loss of anal tone].
      • Cord compression [bilateral pain, LMN signs at level of compression and UMN and sensory signs below, loss of anal tone]
      • Nerve root compression and mechanical symptoms not responding after 6-10 weeks
      • Progressive pain or severe neurological deficit

 If no red flags:

  • Analgesia
    • Regular paracetamol
    • NSAIDS – ibuprofen or diclofenac
      • Consider PPI cover, especially in over 65 year olds.
      • Ensure patient knows to stop PPI when NSAIDS stopped.
    • Tramadol 50mg QDS PRN
      • Generally more appropriate than codeine as these patients are often young so transient confusion with tramadol less likely.
      • Tramadol is also less constipating than codeine.
    • Gabapentin (can be given from the outset)
      • Start at 150mg at night. Titrate over a few days to 300mg TDS.
      • Can go up to 3.6g daily in severe cases.
    • If there is clear paraspinal muscle spasm (can usually feel this) then a short course of PRN low dose benzodiazepines as reasonable.
      • 2mg PRN max TDS
    • Avoid oramorph if possible
  • Education
    • Return to normal activities and gentle exercise is much better than bed rest
    • Avoid precipitants (heavy lifting, poor posture)
    • Give basic advice on posture
  • Address psycho-social issues
  • Safety net
    • Warn re red flag symptoms
    • Refer to physiotherapy if not improving

 

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